The document discusses inflammatory bowel diseases (IBD), specifically ulcerative colitis (UC) and Crohn's disease (CD), detailing their epidemiology, etiopathogenesis, clinical features, diagnostic criteria, and treatment options. It highlights the prevalence rates, diagnostic methods including laboratory tests and imaging, and various therapeutic approaches such as lifestyle changes, medications, and surgeries. Both diseases present distinct macroscopic and microscopic features, affecting the gastrointestinal tract in different ways, and have specific clinical severity classifications.

1. Dr. Mohammad Rehan

2. • It includes a group of chronic disorders that cause
inflammation or ulceration in large and small intestines.
• 2 major types: Ulcerative colitis (UC) and Crohn’s disease
(CD)
INCIDENCE-
 Highest incidence in Europe, the United Kingdom, and North
America.
 Urban areas > rural areas.
 high socioeconomic classes > lower socioeconomic classes.
INFLAMMATORY BOWEL DISEASE

3. • Recently two studies, both from northern India,
reported a population prevalence of ulcerative colitis
(UC) of approximately 42 per 100,000 .
• No such population based study is available for
crohn’s disease.

4. EPIDEMIOLOGY

5. ETIOPATHOGENESIS
 Exact cause is
unknown.
• Genetic factors
• Immunological factors
• Microbial factors
• Psychosocial factors

7. GENETIC FACTORS
• Ulcerative colitis is more common in DR2-related genes.
• Crohn’s disease is more common is DR5 DQ1 alleles.
• 3-20 times higher incidence in first degree relatives.

8. IMMUNOLOGIC FACTORS
• Defective regulation of immunosuppression.
• Activated CD+4 cells activate other inflammatory cells
like macrophages & B-cells or recruit more inflammatory
cells by stimulation of homing receptor on leucocytes &
vascular epithelium resulting in inflammation of mucosa
and sub mucosa.

11. PATHOGENESIS OF IBD
American Gastroenterological Association Institute, Bethesda,
MD. Sartor RB. Nat Clin Pract Gastroenterol Hepatol. 2006;3:390-
407.
Normal
Gut
Tolerance-
controlled
inflammation
(Infection, NSAID, other)
Complete Healing
Chronic Inflammation
Genetically
Susceptible
Host
Acute Inflammation
↓ Immunoregulation, failure of
repair or bacterial clearance
Acute injury
Environmental
triggers

12. PATHOLOGY
Macrocopic features
•Ulcerative colitis
 Usually involves rectum & extends proximally to involve all
or part of colon.
 Spread is in continuity.
 About 40–50% of patients have disease limited to the rectum and
rectosigmoid.
 30–40% have disease extending beyond the sigmoid but not
involving the whole colon, and
 20% have a total colitis (10–20% patients have backwash ilietis).

14.  Mild disease- erythematous & sand paper appearance
(fine granular surface) of mucosa.
 Moderate-marked erythema, coarse granularity, contact
bleeding & no ulceration.
 Severe- spontaneous bleeding, edematous & ulcerated
(collar button ulcer) mucosal surface.
 Long standing-epithelial regeneration so pseudopolyps ,
mucosal atrophy & disorientation leads to a
precancerous condition.
 Eventually can lead to shortening and narrowing of
colon.
 Fulminant disease-Toxic colitis/ megacolon/ perforation

15. ULCERATIVE
COLITIS
Ulcer
Pseudopolyps

16. MICROSCOPIC FEATURES
 Limited to mucosa & sub mucosa
 Crypts atrophy & irregularity
 Superficial erosion
 Diffuse mixed inflammation
 Basal lymphoplasmacytosis

17. Crypt
distortion
Diffuse
inflammation

19. MACROSCOPIC FEATURES
• Crohn’s disease
Can affect any part of GIT.
Transmural involvement.
Segmental with skip lesions.
Cobblestone appearance of mucosa.
Creeping fat- adhesions & fistula.

22. MICROSCOPIC
FEATURES
• Aphthous ulcerations.
• Focal crypt abscesses.
• Granuloma formation- pathognomic.
• Submucosal or subserosal lymphoid
aggregates.
• Transmural involvement with fissure
formation.

25. CLINICAL FEATURES
• Ulcerative colitis
Diarrhea
Rectal bleeding
Tenesmus
Passage of mucus
Crampy abdominal pain
 Systemic symptoms fever, weight loss
 Extra intestinal manifestations

26. • Physical signs
Proctitis – Tender anal canal & blood on rectal
examination.
Extensive disease-tenderness on palpation of
colon.
Toxic colitis-severe pain &bleeding.
If perforation-signs of peritonitis.

27. 1. Truelove SC, et al. Br Med J. 1955;2:1041-1045.
2. Sandborn WJ. Curr Treat Options Gastroenterol.1999;2:113-118.
CLINICAL SEVERITY OF UC
Mild Moderate Severe Fulminant
Bowel movement <4/day Intermediate >6 >10
Blood in stool Intermittent moderate Frequent Continuous
Temperature Normal <37.5° >37.5° >37.5°
Pulse Normal <90bpm >90 bpm >90 bpm
Hemoglobin Normal >75% <75% Transfusion
required
ESR <30 mm/hour >30 mm/hour >30 mm/hour
Clinical signs Abdominal
tenderness
Abdominal
distension and
tenderness

28. EXTRA INTESTINAL MANIFESTATIONS OF
ULCERATIVE COLITIS

29. DIAGNOSIS
• Laboratory tests
• Endoscopy
• Radiography
• Tissue Biopsy

30. LABORATORY TESTS
• Hemogram
 ESR is increased
 Platelet count-increased
 Hemoglobin-decreased
• C-reactive protein is increased
• Fecal Calprotectin levels correlate with histological
inflammation, predict relapses & detect pouchitis.
• Fecal lactoferrin- high levels indicate intestinal
inflammation.

31. BARIUM ENEMA

32. BARIUM ENEMA
• Fine mucosal granularity-
earliest radiological change.
• Superficial ulcers seen
• Collar button ulcers- s/o
mucosal penetration
• Pipe stem appearance- loss of
haustrations
• Narrow & short colon-
• Ribbon contour colon

33. SIGMOIDOSCOPY
• Always abnormal
• Loss of vascular patterns
• Granularity
• Friability
• Ulceration

34. Colonoscopy with acute ulcerative colitis: severe
colon inflammation with erythema, friability, and
exudates.

36. CLINICAL FEATURES
ILEAL CROHN’S DISEASE
 Abdominal pain
 Diarrhea
 Weight loss
 Low grade fever
JEJUNOILEITIS - associated with a loss of digestive
and absorptive surface, resulting in
 Malabsorption
 Steatorrhea

37. Colitis and perianal disease
• Bloody diarrohea
• Passage of mucus
• Lethargy
• Malaise
• Anorexia
• Weight loss
Contd. Clinical features

38. GASTRODUODENAL DISEASE –
• Symptoms and signs of upper GI tract disease include
nausea, vomiting, and epigastric pain.
• The second portion of the duodenum is more commonly
involved than the bulb.
• Patients with advanced gastro duodenal CD may develop a
chronic gastric outlet obstruction.

39. DIAGNOSIS
• Laboratory tests
• Endoscopy
• Radiography
• Biopsy
• CT enterography

40. LABORATORY TESTS
• Anemia
• Leukocytosis
• ESR-elevated
• CRP-elevated
• Hypoalbuminemia

41. BARIUM ENEMA
String sign
Represents long areas of
circumferential inflammation and
fibrosis, resulting in long segments
of luminal narrowing.

42. COLONOSCOPY

43. • Endoscopic features of CD include rectal sparing,
aphthous ulcerations, fistulas, and skip lesions.
• Colonoscopy allows examination and biopsy of
mass lesions or strictures and biopsy of the
terminal ileum.
• Upper endoscopy is useful in diagnosing
gastroduodenal involvement in patients with
upper tract symptoms

45. CT- ENTEROGRAPHY
• Mural hyper
enhancement.
• Stratification.
• Engorged vasa recta.
• Perienteric inflammatory
changes.

48. TREATMENT
LIFE STYLE CHANGES
DIET CHANGE
DRUGS
SURGERY

49. DIETARY
CHANGES
 Eating :
 Low-fat foods.
 Smaller, more
frequent meals.
 Avoiding :
 foods high in
undigestible fiber.
 Refined sugars .

50. LIFESTYLE CHANGES
NO SMOKING
REDUCING STRESSDOING EXERCISE
TAKING REST

51. Therapeutic approach for IBD

52. DRUGS
• 5-ASA agents
• Glucocorticoids
• Antibiotics
• Immunosuppresants
• Biological therapy

53. 5-ASA AGENTS
• Sulfasalazine – combination of 5-aminosalicylic acid( anti
inflammatory ) + sulfapyradine-antibacterial).
 Partially absorbed in jejunum but remainder passes in colon
 Therapeutic action –inhibition of P.G.s & leukotriene
synthesis, free radical scavanging, free radical scavanging,
impairement of white cell adhesion and function, inhibition
of cytokine synthesis.
• Mesalamine group (coating 5-ASA with acrylic resins), e.g.
Asacol, Pentasa, Balsalazide (prodrug of 5-ASA).
• Olsalazine (5-ASA dimer cleaves in colon).

55. Distribution of 5-ASA Preparations
Oral
•Varies by agent: may be released in the
• distal/terminal ileum, or colon1
Suppositories
• Reach the upper rectum2,5
• (15-20 cm beyond the anal verge)
Liquid Enemas
• -May reach the splenic flexure2-4
• -Do not frequently concentrate in the
rectum3
Topical Action of 5-ASA: Extent of Disease
Impacts Formulation Choice
1. Sandborn WJ, et al. Aliment Pharmacol Ther. 2003;17:29-42; 2. Regueiro M, et al. Inflamm Bowel Dis. 2006;12:972–978; 3. Van Bodegraven AA,
et al. Aliment Pharmacol Ther. 1996; 10:327-332; 4. Chapman NJ, et al. Mayo Clin Proc. 1992;62:245-248; 5. Williams CN, et al. Dig Dis Sci. 1987;32:71S-75S.

56.  Use
• Mainstay of OPD treatment for mild to moderate active
UC & Crohns colitis.
• Maintaining remission
• May reduce risk of colorectal cancer
 Adverse effects
• Nausea, headache, epigastric pain, diarrhoea,
hypersensitivity, pancreatitis
• Caution in renal impairment, pregnancy, breast feeding

57. GLUCOCORTICOIDS
• Anti inflammatory agents for moderate to severe
relapses (including IV treatment; enemas for
acute proctitis)
• Inhibition of inflammatory pathways.
• No role in maintenance therapy
• Prednisone-40-60mg/day
• Budesonide- 9mg/dl used for 2-3 months & then
tapered.

58. ANTIBIOTICS
• Metronidazole is effective in active inflammatory,
fistulous & perianal Crohn’s Disease.
 Dose-15-20mg/kg/day in 3 divided doses.
• Ciprofloxacin 500mg BD.
• Rifaximin.
• No role of antibiotics in active/quiescent UC.

59. IMMUNOSUPPRESANTS
• Thiopurines- Azathioprine, 6-mercaptopurine.
• Methotrexate
• Cyclosporine
 Reduce inflammation by suppressing immune system’s
response (which might damage digestive tissue) invading
virus or bacterium.
• Used in patients unresponsive to steroid &
amino salicylates

60. CYCLOSPORINE
 Preventing clonal expansion of T cell subsets.
Use
• Steroid sparing
• Active and chronic disease
Side effects
 Minor: tremor, paresthesias, malaise, headache
gingival hyperplasia, hirsutism.
 Major: renal impairment, infections, neurotoxicity

61. BIOLOGICAL THERAPY
Infliximab
 Anti TNF monoclonal antibody.
 Binds to TNF trimers with high affinity, preventing cytokine from
binding to its receptors.
 It also binds to membrane-bound TNF- a and neutralizes its activity
& also reduces serum TNF levels.
• Use
• Fistulizing CD
• Severe active CD
• Refractory/intolerant of steroids or immunosuppression
• Side effects
• Infusion reactions
• Sepsis
• Reactivation of Tuberculosis
• Increased risk of Tuberculosis

62. • Newer Biologics
1) Adalimumab
2) Certolizumab
3) Golimumab

63. OTHER MEDICATIONS
 Anti- diarrheal - Loperamide
(Imodium)
 Laxatives - senna, bisacodyl
 Pain relievers- acetaminophen
(Tylenol).
 Iron supplements

64. SURGERY
Ulcerative colitis
Indications:
• Fulminating disease.
• Chronic disease with anemia, frequent stools,
urgency & tenesmus.
• Steroid dependent disease.
• Risk of neoplastic change.
• Extra intestinal manifestations.
• Severe hemorrhage or stenosis.

65. • Reconstructive Proctocolectomy with ileoanal
pouch.
• Proctocolectomy & ileostomy.
• Rectal & anal dissection.
• Colectomy with ileorectal anastomosis.
• Ileostomy with intra abdominal pouch.
Surgery in ulcerative colitis

66. OTHERS
• Proctocolectomy & ileostomy.
• Rectal & anal dissection.
• Colectomy with ileorectal anastomosis.
• Ileostomy with intra abdominal pouch.

67. SURGERY IN CROHN’S
DISEASE
• Ileocaecal resection.
• Segmental resection.
• Colectomy & ileorectal anastamosis.
• Temporary loop ileostomy.
• Proctocolectomy.
• Strictureplasty.

70. DIFFERENTIAL DIAGNOSIS OF UC AND CD